Healthcare Provider Details

I. General information

NPI: 1336168228
Provider Name (Legal Business Name): PAMELA L WILSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 10/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 N FLOOD AVE
NORMAN OK
73069-7641
US

IV. Provider business mailing address

905 N FLOOD AVE
NORMAN OK
73069-7641
US

V. Phone/Fax

Practice location:
  • Phone: 405-928-1922
  • Fax:
Mailing address:
  • Phone: 405-928-1922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number3300
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number3300
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: